REGISTRATION FORM
PLEASE FILL IN ALL THE INFORMATION ON EACH OF THE FOUR PAGES RELEVANT TO YOU:
Name: Mr / Mrs / Ms / Miss ___________________________________________________________
Address:
______________________________________________________________________
______________________________________________________________________
Email address: _____________________________________________________________________
Telephone:
Home:__________________Work __________________Mobile:___________________
Current Occupation:_______________________ Course location: _____________________________
Past Occupations:____________________________
MEDICAL HISTORY
Type of Illness: (e.g. Asthma, panic attacks, sleep apnea) ___________________________________
Degree: (e.g. Mild, Moderate, Severe)
___________________________________
Regularity of attacks or problems (daily, weekly, monthly) ___________________________________
Age originally diagnosed: ______________ Date of birth: __________________ Age now: _________
Current Height ________
Current Weight __________
Medical Practitioner: ______________ _____________________ Telephone: ___________________
Last time hospitalized for asthma:
_________________
Date you last took cortisone orally or by
injection (e.g. Prednisone, Prednisolone, Methylprednisone): _______________________
Have you ever suffered from the following problems?:
Current?
Current?
___Angina
Y N ___Depression
Y
N
___Epilepsy
Y N ___Fluid retention
Y
N
___High Blood Press. Y N ___High Cholesterol
Y
N
___Hypoglycemia
Y N ___Kidney Disease
Y
N
___Migraines
Y N ___Overactive Thyroid Y
N
___Schizophrenia
Y N ___Underactive Thyroid Y
N
___Other
Please list other symptoms on Page 3
Current?
___Diabetes
___Heart Condition
___Hyperventilation
___Low Blood Pressure
___Panic attacks
Have you had any major surgeries?
YES ___
NO ___
Have you had any life threatening illnesses?
YES ___
NO ___
Y
Y
Y
Y
Y
N
N
N
N
N
Drugs are you allergic to _________________________________________________
_______________________________________________________________
_______________________________________________________________
What things besides drugs are you allergic to? _______________________________
_______________________________________________________________
_______________________________________________________________
Females, are you pregnant? YES ___
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NO ___
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COMPLETE THIS PAGE IF YOU HAVE ASTHMA, COPD
NAME: _________________________
DATE: ____________
Please list all drugs you are currently taking, or have taken, in the past two months whether related
to breathing difficulties or not.
"Inhaler" Medication:
Dosage
Albuterol
Alupent
Atrovent
Proair
Number of puffs
am
pm
Slow Release Relievers:
Dosage
Foradil
Serevent
Brovana
Zyflo
Number of puffs
am
pm
Preventers:
Inhaled
Aerobid
Asmanex
Azmacort
QVAR
Flovent
Intal
Pulmicort
Vanceril
Number of puffs
am
pm
Dosage
Dosage
Number of puffs
am
pm
Dosage
Number of puffs
am
pm
Dosage
Number of tablets
am
pm
Combivent
Maxair
Proventil
Ventolin
Xopenex
Xolair
Theophylline
Symbicort
Spiriva
ADVAIR*
Tablet
Alvesco
Medrol
Prednisone
Singulair
Tilade
Combined drugs:
Symbicort
ADVAIR*
Nebulizer Use:
Dosage
Albuterol
Atrovent
Ventolin
Duo Neb
Nasal Spray Use:
Dosage
Astelin
Rhinocort
Nasocort
Omnaris
am
pm
Dosage
am
pm
Dosage
am
pm
AccuNeb
Xopenex
am
pm
COMPLETE THIS PAGE WHETHER YOU HAVE ASTHMA OR NOT
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OTHER MEDICATION NOT RELATED TO ASTHMA:
Medication
Condition
Dosage
Do you or did you ever smoke? YES ___
If yes, how many packs per day?_____
AM
PM
Comments
YES, have stopped ___ NO ___ If yes, how long? ____
If stopped, when did you stop smoking?___________
Please explain any surgeries:
____________________________________________________________________________
____________________________________________________________________________
If you checked a life-threatening illness:
Sleep apnea/ snoring
How long ago was it?
_____________________
Was it lung related?
YES ___
NO ___
Have you had a sleep study?
Yes ______
No ______
Was it kidney related?
YES ___
NO ___
Date of test: ______________
Was it heart related?
YES ___
NO ___
Results: __________________
Apneas noted: ____________
If you checked major surgeries:
How long ago was it?
_____________________
Oxygen saturation: _______%
Was it lung related?
YES ___
NO ___
CPAP pressure setting: ______
Was it kidney related?
YES ___
NO ___
Are you using oxygen? Y
Was it heart related?
YES ___
NO ___
What flow rate?
YES ___
NO ___ If yes, which? ________________________
Do you have a blood disorder?
Have you been diagnosed with any chronic condition? YES ___
Are you experiencing chronic pain?
YES ___
N
_______L/M
NO ___ If yes, which? __________
NO ___ If yes, where? ______________________
_______________________________________________________________________________________
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COMPLETE THIS PAGE WHETHER YOU HAVE ASTHMA OR NOT
SYMPTOMS SUFFERED PRIOR TO COMMENCING COURSE
Please check your symptoms:
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) allergies
) anemia
) apathy
) asthma attacks
) bleeding veins
) breathing through mouth
) breathing without pause
) chest pains (not heart)
) constipation
) coughing
) deterioration of vision
) diarrhea
) dizziness
) dryness in mouth
) dryness of skin
) far sightedness
) fear of sultry air
) fear without reason
) flashes before eyes
) frequent deep breaths
) headaches
) impotence
) insomnia
) irritability
) lack of concentration
Please list other symptoms
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) loss of feeling in limbs
) loss of hearing
) loss of libido
) loss of memory
) loss of smell
) mental fatigue
) muscle pains
) painful/irregular periods
) pains in heart region
) pains in bones
) physical exhaustion
) prone to colds and flu
) rhinitis
) ringing or buzzing in ears
) short temper
) shortness of breath
) shuddering in sleep
) snoring
) sudden chilling of limbs
) tightness around chest
) trembling and tic
) varicose veins
) weight gain
) weight loss
) other
__________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I understand that the Buteyko Breathing Reconditioning Program is a series of lectures and training. It
does not constitute medical treatment. Furthermore, I, the undersigned, agree to only modify
prescribed medication after consultation with a medical doctor.
I also agree that as I am not a trained Buteyko Educator I will not attempt to teach other people without
the written permission of Hadas Golan and Buteyko Breathing Educators Association.
Name: ___________________________________.
Date: _________________
Signed: ______________________________________________
If client is under 18, a parent or guardian must sign this form
Please tell me about why you are attending the course and what you hope to gain from it:
____________________________________________________________________________
____________________________________________________________________________
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Last updated 2/17/2016